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SAN JOAOUINi „NTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HsfH DIVISION <br /> I' GST WORKSHEET FOR SITE CLOSURE EVALUATION <br /> GATE <br /> NAME OF FACILT TY <br /> FL �� SWEEPS CODE <br /> ADDRESS Q1b00 IZ-All 90 TANK ID # <br /> '�. - `�50lv0b\ <br /> TANK SIZE FUEL TYPE D� U` <br /> 11. GENERAL SITE HISTORY <br /> Is permit current? Yes No Permit # - *** <br /> Facility Status Code DOc.$oit/GW Cont Yes No <br /> Number of Tanks at facility Age of Tani available) Type of Tank SteelFbrgl Sngl Dual <br /> 111. TANK HISTORY <br /> Was Tank tested? Yes No Failed precision test ? Yes No if yes, give dates) <br /> Was a repair made to the tank system? Yes No If yes, what was repaired? <br /> Was repair done under inspection? Yes No Were soil saaptes analyzed! Yes No BTXE TPH-G TPH-D Pb/EDB <br /> Type of failure/discharge catastrophic tong-term leakage overfill unknown other: <br /> !V. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes v/ No Depth to Ground Water Ref/Year Average Annual Precipitation A= 14 10-25 <br /> On-Site Wells) Yes No Number 8 Type Irr Dom Pub <br /> S Score SFcndition <br /> S Score <br /> Distance to Wells) from Tank ft; ft; ft C 10 pts CC 5 pts <br /> 0 if 00 if <br /> R condition R R condition <br /> V. Site Feature - Leaching Potential Analysis E is met EE is met <br /> Minimum Depth to groundwater from the Soil Sampte (feet) >100 51-100 25-50\1 <br /> Fractures in subsurface (applies to foothills or mountain areas) None ✓ Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9 10-25 xxxxxxx 26-40\2 <br /> Man-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water welts, ponds) None Unknown Present <br /> Unique site features: Recharge area, coarse soil, nearby wells. p� At least More than <br /> xxxxxx None one 5 one <br /> AN <br /> COLUMN TOTALS>>>TOTAL POINTS VP + 15 = 33 <br /> Sample Result: IS T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> B T KE B T X E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. Ni <br /> I 1 <br /> Sample Result: - GASOLINE 1000 100 10 <br /> MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> a\d TPN DIESEL r 10,000 10 100 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do complete the leach mal <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> . STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPH Concentrati s > Atlo bte Levels *YesNo <br /> 2. Recommend Site Closure Yes• No *!f Yes, Refer to Site Mitigation for Evaluation <br /> I. REVIEW EVALUATION - TO BE COM ETED BY A SUPERVISOR/SENIOR <br /> CONCUR,,WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EN 23 80 (UGTWKSHT)\5/90 - <br />